Exploring The Development Of Multicultural Counseling Competence Nursing Essay
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Over the years multicultural counseling competence (MCC) has developed into a topic that is widely discussed in the human service professions (Pope-Davis, Coleman, Liu, & Toporek, 2003). Social work, applied psychology, counseling, psychiatry, education and health care, as well as many other disciplines, have all embraced the importance of MCC. Additionally, these fields have all developed and implemented techniques to monitor and foster the practice of MCC (Pope-Davis et al., 2003). The purpose of this paper will be to explore the historical development of MCC, as well as discuss the literature, themes and issues involved in multicultural counseling competence.
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Historical Development of Multicultural Counseling Competence
In 1973 cultural diversity and its importance to psychological practice was brought to the forefront during the Vail Conference (Pope-Davis et al., 2003). As a result of this conference it was deemed that providing professional services to culturally diverse individuals is unethical if the clinician is not competent to do so. Furthermore, it was decided that graduate programs should teach appropriate cultural content in order to ensure that graduate students are able to competently treat diverse populations (Pope-Davis et al., 2003). Sue and Sue (1977) contributed to these ideas with their article entitled “Barriers to Effective Cross-Cultural Counseling.” In this article it was suggested that breakdowns in communication may occur between the counselor and client due to the counselor’s inability to fully interpret cultural messages from the client and in turn convey culturally relevant information. Additionally, Sue and Sue (1977) postulated that counseling techniques in the United States may conflict with the values of individuals from Third World groups, and thus cause the communications between the counselor and client to become distorted in cross-cultural counseling. After this article was published, interest and support greatly increased for MCC in applied psychology and other related fields.
The earliest MCC literature focused on defining MCC and developing ways for counselors to become multiculturally competent (Pope-Davis et al., 2003). During the 1980s the concepts that have become central to cross-cultural counseling competencies began to be developed. In 1982, Sue et al. developed three competencies that have served as the basis for many studies over the past two decades (e.g., Constantine & Landay, 2000; Ponterotto & Casas, 1985; Ramsey, 1995). The proposed competencies consisted of beliefs and attitudes, knowledge and skills. A decade after these competencies were introduced, Sue, Arredondo, and McDavis (1992) published another article that requested that the field of psychology employ multicultural counseling competencies and standards in counseling practice and education. This article also presented a rationale for multicultural perspectives in psychological assessment, training, and research; outlined standards for culturally competent practice; and promoted the incorporation of these standards in the American Association for Counseling and Development (AACD).
The efforts to define MMC were subsequently followed by attempts at developing guidelines for multicultural competent training programs and curricula. Literature addressing the issue of multicultural competence training began being published in the mid-1980s (Pope-Davis et al., 2003). The primary focus of this literature was on multiculturally competent training practices, supervision, and training programs. The literature in the 1990’s shifted its focus to the assessment of MCC. This literature involved the development of MCC assessment instruments for training, practice, and supervision, in addition to the analysis of these assessment instruments (Pope-Davis et al., 2003). Currently, literature exploring the specialized applications of MCC has become a popular topic. Specialized applications involve the implementation of MCC strategies while working with distinct populations such as individuals with disabilities, terminal illnesses, and children and families (Pope-Davis et al., 2003).
While interest in the topic of MCC has grown greatly in the counseling field over the last several years, the mental health professions were slow to respond to the earlier calls for action. Their slow response is demonstrated by the fact that only a few publications on the topic appeared between 1982 and 1994 (e.g., Carney & Kahn, 1984; Ponterotto & Casas, 1987). It wasn’t until 1994 that more than one publication addressing MCC appeared in the literature during a single year (e.g., Ponterotto, Rieger, Barrett, & Sparks, 1994; Pope-Davis & Dings, 1994; Sodowsky, Taffe, Gutkin, & Wise, 1994). Another significant period occurred from 1997 through 1998 during which time the MCC literature flourished, and the AACD began to endorse the guidelines for cultural competence which contributed greatly to the development of MCC (Pope-Davis et al., 2003). The American Psychological Association (APA, 1999) began endorsing the guidelines for cultural competence the following year.
The Literature That Surrounds MCC
Pope-Davis et al. (2003) suggested that MMC literature is typically grouped into five different categories: (a) asserting the importance of MCC; (b) characteristics, features, dimensions, and parameters or MCC; (c) MCC training and supervision; (d) assessing MCC; and (e) specialized applications of MCC.
Asserting the Importance of MCC
Throughout the literature MCC is presented as a vital part of the training, supervision, and practice of counselors (Pope-Davis et al., 2003). Numerous psychologists have continued to assert the importance of MCC to the field of counseling since Sue et al.’s (1982) landmark paper was published. In this paper Sue and colleagues (1982) stated the counseling professions needed to focus more on inclusivity, community mindedness, and concern for justice. Additionally, they suggested that all mental health professionals prepare themselves to provide culturally appropriate counseling to diverse populations due to the significant increase in the non-Caucasian population of the United States. Since the need for MCC application in the mental health profession steadily grew after the publishing of that paper, Sue et al. (1992) called for action in the development and implementation of detailed multicultural counseling standards throughout all facets of the mental health profession. Furthermore, they stated that it is unethical for mental health professionals to work with individuals from diverse backgrounds when they are not competent to do so, and that doing so may harm these individuals.
Silva-Netto (1994) furthered the rationale for MCC by insisting that the growing acknowledgement of cross-cultural relationships in the field of counseling emphasizes the need for all mental health professionals to acquire cross-cultural competence. Furthermore, it was suggested that since the field of counseling psychology claims to be inclusive it should expand the definition of counseling competencies so that counselors can provide individuals from all cultural backgrounds ethical and proper counseling.
Asserting the importance of MCC in counselor training programs also appears in the literature regularly, however the actual practice of training counselors to be multiculturally competent is still inadequate. Both Allison, Echemendia, Crawford, and Robinson (1996) and Holcomb-McCoy and Myers (1999) assert that it is essential for the field of psychology to better prepare counselors to provide culturally appropriate psychological services to members of ethnic minorities. It is suggested that this can be accomplished by more thoroughly promoting cultural competence in all psychologists. Moreover, Holcomb-McCoy (2000) suggested that further research should be commenced to establish specific competencies and factors that are involved in MCC, and that training programs could use this research to better train their students.
The importance of MCC while working with specific populations has also been stressed in the literature. Imber-Black (1997) stated that regardless of an individual’s profession it is critical to have the skills that facilitate effective cross-cultural communications when working with children and families. In addition to working with children and families, it has been asserted that there is a need to be culturally competent when working with special populations such as HIV patients and their families (Ka’opua, 1998). There has also been literature that has called for the mental health professionals to provide special attention to the needs of ethnic minorities that may feel victimized by the managed health care system (Pope-Davis et al., 2003).
Finally, it has been suggested that mental health professionals should try to interact with their clients in a way that compliments the client’s cognitive, behavioral, and emotional abilities and strengths (Hubble, Duncan, & Miller, 1999). Moreover, the literature suggests that for any relation to continue to be functional over a period of time the relationship must be complementary (Tracy and Ray, 1984). Developing a complementary relationship is a technique that can assist counselors in keeping their clients responsive to their suggestions and actively engaged in the therapy. Since certain groups of individuals, such as those from lower socioeconomic backgrounds, frequently terminate therapy prematurely, it is especially important for counselors who are culturally competent to realize this issue and be able to develop complementary relationships with these groups to assist their therapeutic progress (Garfield, 1986).
Components of MCC
The components of MCC are discussed in the literature through exploring multicultural competencies, proposed models of MCC, and the development of a general definition of MCC.
As previously discussed, Sue et al. (1982) were the first to postulate MCC as being composed of three main components: beliefs and attitudes, knowledge, and skills. The beliefs and attitudes component refers to the counselor’s mind-set about racial minorities. Additionally this component involves counselors noticing their biases, developing a positive orientation toward multicultural perspectives, and recognizing how these biases can influence their cross-cultural counseling relationships (Pope-Davis et al., 2003). The knowledge component encompasses the understanding counselors have of cultural groups, and their understanding of sociopolitical influences on their relationships with individuals from different cultures. Lastly, the skills component refers to the specific abilities necessary for counselors to work with ethnic minorities.
Although the three competences listed above are generally considered to be a useful framework in which to conceptualize MCC and have been supported empirically as being major components of MCC (Holcomb-McCoy, 2000), some researchers have suggested that these competences are not sufficient for total multicultural competence. The Multicultural Counseling Inventory was developed to operationalize proposed constructs of multicultural counseling competencies (Sodowsky et al., 1994). After developing the Multicultural Counseling Inventory, Sodowsky et al. (1994) conducted a factor analysis with the instrument and found a fourth factor of MCC: multicultural counseling relationships. Multicultural counseling relationships refer to the interactional process that occurs between a counselor and a client who is a member of an ethnic minority group. More recent literature suggests that multicultural terminology, the counselor’s ability to understand terminology used to discuss multicultural issues, and racial identity development are other key components in establishing MCC (Holcomb-McCoy, 2000).
The need for a broader conceptualization of the construct of multicultural competence was suggested by Constantine and Ladany (2001) so that counselors can comprehend how multicultural competence is achieved. In order to accomplish this, Constantine and Ladany (2001) proposed that MCC should consist of six competencies: (a) self-awareness, (b) general multicultural knowledge, (c) multicultural counseling self-efficacy, (d) ability to understand unique client variables, (e) effective counseling alliance, and (f) multicultural counseling skills. According to the authors, the degree of MCC possessed by a counselor could be determined by identifying what level has been achieved by the counselor in each competence.
Definitions of MCC
Over the years scholars have offered a variety of broad definitions of MCC. One definition posed by Holcomb-McCoy and Myers (1999) stated that a multiculturally competent counselor possess the skills necessary to work effectively and sensitively with clients from diverse cultural backgrounds. Sue et al. (1992) suggested that in order for counselors to become multiculturally competent they must (a) become aware of their own biases and values related to ethnic minorities; (b) work to understand the worldviews of their clients without passing judgments; and (c) develop and implement culturally sensitive techniques in their own practice.
Additional research has suggested that there are three primary factors that all multicultural counseling competencies are based on: (a) knowledge of the experiences that various cultural groups may have, (b) knowledge of the barriers that are present as a result of cultural differences, and (c) a set of abilities that add to the cultural proficiencies of a counselor (Pope-Davis & Dings, 1995).
Models of Multicultural Competence
Carney and Kahn (1984) introduced one of the first models of multicultural competence. They proposed a five-stage developmental model for the process of gaining multicultural competence. This model suggests that a counselor starts with limited knowledge of other cultural groups, and then through gaining knowledge related to MCC counselors eventually advance to an activist position (Pope-Davis et al., 2003). Each stage of this model demonstrates a pattern of growth in three domains: knowledge of cultural groups; attitude, awareness, and sensitivity; and specific cross-cultural skills (Carney and Kahn, 1984).
Beckett, Dungee-Anderson, Cox, and Daily (1997) posed another model entitled the “multicultural communication process model.” This model is intended to increase multicultural counseling competence in a counseling relationship. The multicultural communication process model is composed of eight competencies associated with MCC: (a) knowledge of self, (b) acknowledgement of cultural differences, (c) identification of differences, (d) knowledge of other cultures, (e) identification and avoidance of stereotypes, (f) empathy for people of other cultures, (g) ability to adapt rather than adopt, and (h) ability to acquire recovery skills. This model was intended to be used by practitioners to first guide their growth in multicultural perspectives, and then to inform their interventions in a multicultural context.
Shortly after the multicultural communication process model was published, Castro (1998) proposed a unique three-factor model for rating the capacity of mental health professionals. Castro (1998) proposed that a practitioner’s “cultural capacity” can range from a level of -3, cultural destructiveness, to +3, cultural proficiency. This model places cultural proficiency above cultural competence. Cultural proficiency requires practitioners to strive for excellence when working with minority populations, and possess a proactive attitude in designing and implementing strategies with various cultural groups. Thus, Castro (1998) asserted that a practitioner’s ultimate goal should be to achieve cultural proficiency.
Lopez (1997) developed a model of cultural competency that focused on the importance of recognizing the cultural viewpoints of the counselor and the client, as well as recognizing the counselor’s ability to move between both points of view. Lopez (1997) stated that first counselors must develop the ability to balance both their point of view and that of the clients’ by engaging the clients in the therapeutic process, and addressing the clients’ actual concerns rather than the concerns the counselors may assume they have. Next, it was suggested that the information collected about the client should be culturally responsive, with special attention paid to the cultural variables that contribute to the results of every assessment tool. Lopez (1997) suggests that counselors should use several instruments, adjust their interpretation based on clients’ cultural background, and use their clinical judgment when considering all cultural data. Additionally, he suggested that counselors should utilize a method of intervention that is in line with the clients’ personality, rather than only utilizing a single theoretical approach.
Lastly, a model named the multiple dimensions of cultural competence (MDCC) was proposed to provide a framework for organizing culture-specific attributes of competence (including African American, Asian American, Latino American, Native American, and European American cultures), components of cultural competence (awareness of beliefs and attitudes, knowledge, and skills), and foci of cultural competence (including societal, organizational, professional, and individual structures; Sue, 2001a). Sue (2001a) stated that this model could be used by a variety of health care professionals to identify cultural competence in various areas.
Multicultural Counseling Training and Supervision
Literature addressing MCC training and supervision generally focuses on identifying training variables, proposing guidelines for multiculturally competent training programs, and investigating multiculturally competent counselor training (Pope-Davis et al., 2003).
MCC Training Variables
The literature dedicated to exploring the training variables that contribute to a counselor’s multicultural counseling competence frequently cites exposure to a variety of cultural groups as an important variable (Allison et al., 1996; Salzman, 2000). It is suggested that counseling trainees who have had contact with clients that are from a different culture than their own report an increase in their MCC as they progress through training (Allison et al., 1996). Furthermore, trainees report that exposure to ethnically diverse speakers and other multicultural events increase their sense of MCC (Neville, Heppner, Thompson, Brooks, & Baker, 1996).
Salzman (2000) proposed three reasons that exposure to multicultural events leads to increased multicultural competence. First, trainees are able to gain awareness of cultural differences. Second, trainees exposed to multicultural events are more apt to explore their own cultural influences. Lastly, trainees are able to gain awareness of the dynamics involved in cross-cultural interactions.
Due to the growing need for MCC training, research has been conducted to assist counselor training programs in meeting specific multicultural competency standards. Pope-Davis and Dings (1995) suggested that training programs should strive to meet specific multicultural competency standards due to the American population becoming increasingly more diverse. In order to properly train counselors McRae and Johnson (1991) suggested multicultural training should emphasize (a) trainees’ knowledge of themselves as cultural beings, (b) trainees’ ability to appropriately relate to clients from a variety of cultural backgrounds, (c) trainees’ ability to promote accurate perceptions of all cultural groups, and (d) trainees’ ability to develop productive multicultural counseling relationships.
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After conducting research on training programs in the United States, Tomlinson-Clarke and Wang (1999) suggested that programs should adopt a four-part curriculum. First, it was proposed that a course that provides awareness of community, social, cultural, and political institutions and their impact on human systems should be included in the training curriculum. Next, they suggested that an experiential component focusing on students’ self-examination and self-evaluation as cultural beings also be included. The third component they proposed was that students should partake in a research practicum where they carry out multicultural research. The final component involves having students enroll in a clinical practicum in order for them to apply the knowledge gained from the three subsequent components.
Specific steps for implementing MCC standards in counselor training programs curricula have been proposed in the literature. The Multicultural Competency Checklist is a 22-item list utilized by training programs to guide them through the process of developing multicultural competence (Ponterotto, Alexander, & Grieger, 1995). The checklist separates the 22-items into six major themes, including minority representation, curriculum, counseling practice and supervision, research, student and faculty competency assessment, and physical environment. The literature suggests that through successfully addressing each of these six major themes training programs are able to ensure multicultural competence throughout their curricula.
Another important component to multicultural counselor education is multicultural coursework (Pope-Davis et al., 2003). Wisnia and Falendar (1999) suggested that an experiential seminar involving counselors’ accessing their own cultural maps, accessing their clients’ cultural maps, and developing an understanding of the similarities and conflicts of the two cultural maps helps counseling students develop multicultural competence. Additionally, the literature suggests that even brief seminars designed to enhance multicultural competence in ethical and assessment issues are effective in increasing students’ multicultural competence (Byington, Fischer, Walker, & Freedman, 1997). However, Sue (2001a, 2001b) stated that while seminars in multiculturalism are effective techniques for teaching, training programs must also provide additional educational activities that take place outside of the classroom. Sue (2001a, 2001b) emphasized that counselor training programs should integrate activities that enable students to gain firsthand experience with individuals from a variety of cultures.
Multiculturally Competent Supervision
While supervision is a main component to counselor training, the literature discussing supervision often overlooks the features that contribute to multiculturally competent supervision (Pope-Davis et al., 2003). Ashby and Cheatham (1996) stated that supervisors are often not sufficiently trained to work with counselor-trainees who differ from them culturally. In order to assist counseling supervisors develop multicultural competence several general guidelines have been defined. One guideline proposed by D’Andrea and Daniels (1997) stated that supervisors should focus not only on increasing their supervisees’ levels of MCC but also focus on increasing their own levels of multicultural supervision competence. Additionally, it was proposed that supervisors should request feedback from students about the students’ perception of the supervisors’ efforts to facilitate a positive multicultural relationship with them within the supervision context. A few final guidelines to multiculturally competent supervision include educating oneself about a variety of cultural groups, allowing issues between the supervisee and supervisor to surface in supervision, using supervisory techniques that meet the needs of the supervisee, and seeking out consultation about multicultural counseling supervision (Ashby & Cheatham, 1996).
Assessment of MCC
The majority of literature focusing on the assessment of MCC consists of the presentation and analysis of assessment instruments (Pope-Davis et al., 2003) Thus, this section of the paper will focus on both the instruments used to assess MCC, as well the problematic areas of the instruments.
Multicultural Competence Instruments
Over the years several instruments have been specifically designed to measure the multicultural competence of counselors. One example is the Cross-Cultural Counseling Inventory-Revised (CCCI-R; LaFromboise, Coleman, & Hernandez, 1991). This instrument is a 20-item Likert-type tool developed to assess a counselor’s effectiveness with clients from a variety of cultural backgrounds (Ponterotto, Rieger, Barret, & Sparks, 1994). The CCCI-R was the first instrument developed to test multicultural counseling competence. The Multicultural Counseling Awareness Scale-Form B: Revised Self Assessment (MCAS:B) was developed by Ponterotto, Sanchez, and Magids (1991) in order to measure counselors’ multicultural knowledge, skills, and awareness. This instrument uses a 7-point Likert-type format as well as a demographic questionnaire. D’Andrea, Daniels, and Heck (1991) developed the Multicultural Awareness-Knowledge-Skills Survey (MAKSS) to assess the effects of multicultural instruction on students’ development of multicultural MCC. The MAKSS entails 8 demographic items and 60 survey items measured on a 4-point scale. The 60 survey items are divided equally into three subscales that assess counselors’ awareness, knowledge, and skills.
One of the most common self-report instruments for measuring multicultural counseling competencies is the Multicultural Counseling Inventory (MCI; Sodowsky et al., 1994). The MCI was developed to operationalize the proposed constructs of MCC. In addition to the three major dimensions of MCC, this instrument identified a fourth factor, multicultural counseling relationships, as being a crucial component to MCC. Lastly, the Personal Cultural Perspective Profile (PCPP) is a 14-item cultural continuum developed to be used as an educational and training tool. The PCPP divides the concepts of culture into 14 cultural continua that assist counselors in better understanding cultural complexities.
MCC Assessment Issues
While the self-report format of MCC assessment has its benefits, researchers have emphasized that these assessment instruments have limitations (Ponterotto et al., 1994). Constantine (2000) suggested that since counselor self-report is a popular form of assessing MCC, the effect of social desirability on self-report is an important variable to investigate. Constantine and Ladany (2000) explored the effects of social desirability on five different self-report assessments and found that social desirability was related to self-reports of MCC, especially in the MCI Relationship subscale, the CCCI-R, and the MAKSS Skill subscale. Additionally, findings from a study conducted by Worthington, Mobley, Franks, and Tan (2000) stated that social desirability and self-reported MCC are positively associated. Thus, follow up research needs to be conducted to compare the relationship between instrument scores and the actual behaviors of counselors. Content validity in regard to MCC assessment instruments is another factor that the literature suggests needs to be addressed (Pope-Davis et al., 2003). In a study evaluating the MCAS:B and the MCI for content validity and interinstrument correlations of their subscales it was found that the two instruments measure different things since the MCI items are expressed in behavioral terms and the MCAS:B items are expressed in terms of beliefs and attitudes (Pope-Davis & Dings 1994).
Although MCC assessment instruments have their limitations there are several appropriate uses including: (a) using the instruments as self-report measures in counseling supervision; (b) using the instruments to evaluate the efficacy of multicultural training seminars and courses; and (c) using the instruments to track the development of counselors’ multicultural competence through the training process (Pope-Davis & Dings, 1994).
Another popular instrument used to assess MCC is portfolio assessment (Pope-Davis et al., 2003). The use of portfolio assessments enables a supervisor in the field of counseling to determine how a trainee’s knowledge and skills about a particular topic have changed over time. Furthermore, it has been suggested that portfolios promote a sense of ownership that assessment instruments do not. Since information from trainees is collected over time about their knowledge, skills, and multicultural awareness a supervisor can make decisions about what would benefit trainees the most in relation to their multicultural counseling development (Pope-Davis et al., 2003).
Applications of MCC in Special Populations
The literature suggests a variety of applications of MCC in special populations (Pope-Davis et al., 2003). One of the main areas of focus for the application of MCC is managed health care. Corcoran and Vandeline (1996) suggested that clinicians should try to identify the local needs and attitudes about mental health services in order for managed health care to work effectively for individuals from all cultures. Moreover, they suggest that culturally competent clinicians in managed health care settings should (a) be able to define a client’s presenting problem and provide outcomes that make sense to the client, (b) be able to develop culturally sensitive diagnostic impressions to reduce misdiagnosis, (c) be able to consider organizational structures that may influence a client’s trust in service providers, and (d) be able to guarantee affordable and cultural sensitive services.
In addition to the application of MCC in managed health care, it has been suggested that another area of specialized application of MCC is children and families. Ariel (1999) suggested that every family has a culture that is composed of the communities of membership in addition to individual cultural components unique to that family. Thus, it is important for counselors to fully understand the cultures of their clients’ families in order effectively treat them.
Throughout this paper the major historical developments and themes in the literature have been briefly discussed. The literature presented here clearly demonstrates the importance of MCC in a variety of counseling settings. These settings include training, supervision, assessment, and practice. While interest in multicultural competence and multicultural competencies has grown greatly over the years, there are still many essential issues that need to be more clearly addressed. First, the dimensions and features of MCC need to be clearly defined. Defining these characteristics would enable practitioners to more consistently and effectively apply multicultural competencies to their work. Next, cultural knowledge needs to be defined more clearly in order for counseling students and practitioners to more easily identify both their areas of competence and areas that they need to approve upon. Lastly, there needs be more research conducted to further distinguish between the features of MCC and those of counseling competence. This research would help clarify the specific skills involved in multiculturally competent counseling practice.
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